Surgical outcomes following strabismus surgery for abducens nerve palsy.

PURPOSE: To assess ocular alignment outcomes and their stability for patients who underwent strabismus surgery for abducens nerve palsy and to identify preoperative patient variables that predict surgical success or repeated surgeries. METHODS: We retrospectively reviewed the medical records of patients diagnosed with abducens nerve palsy and who subsequently underwent strabismus surgery. RESULTS: A total of 209 patients (386 procedures) were included. The mean number of surgeries for patients was 1.9 ± 1.4. Success was achieved after a single surgery for 112 patients (53.6%), and success was achieved for an additional 42 patients, for a total of 154 patients (73.7%), following all surgeries. Preoperative abduction deficit severity was the only variable predictive of surgical success, with mild deficits having the highest odds of both initial success (OR = 5.555; CI, 2.722-11.336) and final success (OR = 5.294; 95% CI, 1.931-14.512). When analyzing survival time until additional surgery, the median survival was 406 days; abduction deficit severity, older age, other coincidental motility abnormalities, greater magnitude esotropia, and surgical technique were predictive of repeat surgical incidence. CONCLUSIONS: In our patient cohort, preoperative abduction deficit was an important predictor of both surgical success and repeat surgical incidence for abducens nerve palsy. Older patient age, additional motility abnormalities, and greater amounts of baseline strabismus were also associated with greater likelihood of multiple surgeries.

Superonasal Transconjunctival Optic Nerve Sheath Decompression: A Simplified Technique for Safe and Efficient Decompression.

BACKGROUND: Severe, permanent vision loss is a feared sequela of untreated or refractory idiopathic intracranial hypertension (IIH). For patients with progressive vision loss despite maximally tolerated medical treatment, optic nerve sheath decompression (ONSD) remains a viable and effective option to protect vision. Our objective is to introduce a modified transconjunctival technique for ONSD and determine its safety, efficacy, and efficiency in patients with IIH. METHODS: We performed analyses for a retrospective case series of consecutive patients with IIH by modified dandy criteria who underwent isolated superonasal transconjunctival optic nerve sheath decompression (stOND) at single eye institute in a large academic center from January 2013 to February 2017. Sixty-six patients were identified who met these criteria with at least 6 weeks of follow-up data. Primary outcome measures were visual field mean deviation, grading of papilledema by the modified Frisen scale, and best-corrected visual acuity. Secondary outcome measures were presence of postoperative diplopia and operative time. RESULTS: One hundred thirty-two eyes of 66 patients were identified; 58 were female (88%), and 8 were male (12%). The mean age was 30 years (range 13-55) with an average lumbar puncture opening pressure of 38 cm H2O. Participants mean body mass index was 36 (range 20-59) with Grade 3 papilledema on average by the modified Frisen scale. No patients experienced operative complications, postoperative diplopia, or worse visual acuity at 1 week after surgery. Average operative time was 50 minutes (range: 25-89). The median decrease in papilledema grading was 3 grades on the Frisen scale (95% confidence interval [CI], 2-3, P < 0.0001). Snellen visual acuity changes did not meet statistical significance. The average Humphrey Visual Field mean deviation change was +1.91 (95% CI, 0.58-3.24, P = 0.0052). Despite successful bilateral decompressions, 4 patients (6.1%) progressed in their visual loss. CONCLUSIONS: The superonasal transconjunctival approach to ONSD is a safe, efficient and effective surgical treatment for patients with deteriorating visual function due to IIH. Although additional study is required to further clarify the best timing and indications for ONSD among other treatment options for refractory IIH, providers should be aware of the reduced complication rates and efficacy of the stOND technique.

Comparison of Objective and Subjective Techniques of Strabismus Measurement in Adults With Normal Retinal Correspondence.

PURPOSE: Accurate measurement of strabismus is vital to proper diagnosis and treatment. Objective and subjective measurement techniques can be used. The authors hypothesized that subjective measurement techniques would measure larger deviations than objective ones. METHODS: Adults with strabismus, visual acuity greater than 20/50 in each eye, and normal retinal correspondence were measured in primary gaze at distance and near using the alternate prism and cover test and the red glass test. RESULTS: Seventy-three patients were prospectively enrolled. Objective mean deviations were 9.1 (distance horizontal), 5.1 (distance vertical), 10.0 (near horizontal), and 2.6 (near vertical) prism diopters (PD). Subjective mean deviations were 10.2 (distance horizontal), 6.8 (distance vertical), 12.2 (near horizontal), and 3.2 (near vertical) PD. Subjective measurements were larger by a statistically significant margin and were more likely to show the presence of a vertical deviation not measured objectively (19 occurrences vs 2 at near, P = .008; 15 occurrences vs 0 at distance, P = .004). The measured deviations were within 5 PD horizontally and 3 PD vertically most of the time (range: 66.7% to 83.6%). CONCLUSIONS: The red glass test was more likely to measure a larger deviation at distance and near and to identify a vertical deviation not seen objectively at both distance and near. The mean difference between the tests was usually not large enough to affect surgical treatment, but could potentially result in different amounts of prescribed prism for patients treated optically. [J Pediatr Ophthalmol Strabismus. 2017;54(4):216-220.].

Update on the application of optic nerve sheath fenestration.

BACKGROUND: With the ongoing development of surgical procedures and instruments, the safety of optic nerve sheath fenestration (ONSF) has been improved. OBJECTIVE: Through the past three decades, progress has been made in preventing visual loss from chronic optic nerve swelling in idiopathic intracranial hypertension (IIH), secondary intracranial hypertension and local optic nerve diseases. We now review the updated application of ONSF in those diseases. METHODS: The application of ONSF in papilledema due to IIH, secondary intracranial hypertension to cerebral venous sinus occlusion, Cryptococcal meningitis, and intracranial mass or tumors is reviewed. Additionally, the potential benefits of ONSF in local optic neuropathy from optic nerve sheath meningioma, optic nerve drusen, traumatic optic neuropathy and optic nerve/sheath biopsy are also described. RESULTS: Although ONSF has little or no effect on intracranial pressure, it is a safe, relative easy and effective surgical procedure to prevent or reverse visual loss in IIH. When other treatment modalities fail to timely protect vision, ONSF can be useful in protecting visual function or delay visual loss in secondary intracranial hypertension. CONCLUSION: We recommend that ONSF should be considered as a meaningful alternative or an adjunct therapy to reduce or delay the visual morbidity of these diseases, although the use of ONSF for some of them remains controversial.

Acetazolamide: A New Treatment for Visual Vertigo.

Visual vertigo is a disorder characterised by symptoms of dizziness, vertigo, unsteadiness, disorientation, and general discomfort induced by visual triggers. It is currently treated with vestibular rehabilitation therapy, with no effective pharmacotherapy available for treatment-resistant cases. The objective of this study was to evaluate the efficacy of oral acetazolamide in improving symptoms of visual vertigo. A comparative case series of adult patients clinically diagnosed with visual vertigo was conducted from January 1992 to May 2015. Patients without a full neurologic or otorhinolaryngologic work-up, negative magnetic resonance imaging (MRI), and an organic cause for their symptoms were excluded. The identified patients were then contacted by phone to complete a voluntary symptom survey. Main outcome was the subjective reported percentage in symptom improvement. Secondary outcomes were subjective improvement by symptom triggers. The participants were retrospectively divided into three groups based on their treatment with acetazolamide: currently on acetazolamide, terminated acetazolamide, or never initiated acetazolamide. Fifty-seven patients met the inclusion criteria and were willing to complete the phone survey (19 currently on acetazolamide, 27 terminated acetazolamide, and 11 never initiated therapy). Overall symptomatic improvement was reported by 18 (94.7%) patients currently on acetazolamide, 18 (66.7 %) who terminated acetazolamide, and 5 (45.5%) who never initiated therapy, varying significantly by group (p = 0.0061). Greatest improvement was reported in symptoms triggered by being a passenger in a car. These results show that acetazolamide has a positive association with improvement of symptoms of visual vertigo.

The Relationship Between Optic Nerve Sheath Decompression Failure and Intracranial Pressure in Idiopathic Intracranial Hypertension.

BACKGROUND: To our knowledge, there are no studies of patients with idiopathic intracranial hypertension (IIH) that address the relationship between level of intracranial pressure (ICP) and likelihood of progressive visual loss despite uncomplicated optic nerve sheath decompression (ONSD). This study investigated whether patients with IIH undergoing ONSD had a higher risk of surgical failure if opening pressure (OP) on lumbar puncture was ≥50 cm H2O compared to those with OP <50 cm H2O. METHODS: We conducted a retrospective chart review of consecutive patients with IIH who failed maximal medical therapy and underwent ONSD between January, 1992 and November, 2014, and were followed at least 3 months postoperatively. The main outcome measure was the relationship between OP on lumbar puncture and ONSD failure. We also investigated the relationship of OP with visual acuity, visual fields, age, and gender. RESULTS: During this period, 174 patients met inclusion criteria. Of the 40 patients who had an OP ≥50 cm H2O, 6 (15%) had progressive visual loss after uncomplicated ONSD, vs 6 (4.5%) of 134 patients with an OP <50 cm H2O (P = 0.032, Fisher exact test). Patients with worse visual acuity at presentation also had a higher risk of progressive visual loss after ONSD (P < 0.001, Cochran-Armitage trend test), as did men (P = 0.048, Fisher exact test). CONCLUSIONS: Patients with IIH and an OP ≥50 cm H2O had a 3-fold increased risk of failure of ONSD to prevent progressive visual loss, requiring a shunting procedure when compared to those with OP <50 cm H2O. Visual acuity at presentation and male sex also were associated with progressive visual decline after ONSD. These risk factors merit closer follow-up in the postoperative period when signs of further visual deterioration would indicate an urgent need for neurosurgical shunting.

Farris-Tang retractor in optic nerve sheath decompression surgery.

PURPOSE: Our purpose is to introduce the use of the Farris-Tang retractor in optic nerve sheath decompression surgery. METHODS: The procedure of optic nerve sheath fenestration was reviewed at our tertiary care teaching hospital, including the use of the Farris-Tang retractor. RESULTS: Pseudotumor cerebri is a syndrome of increased intracranial pressure without a clear cause. Surgical treatment can be effective in cases in which medical therapy has failed and disc swelling with visual field loss progresses. Optic nerve sheath decompression surgery (ONDS) involves cutting slits or windows in the optic nerve sheath to allow cerebrospinal fluid to escape, reducing the pressure around the optic nerve. We introduce the Farris-Tang retractor, a retractor that allows for excellent visualization of the optic nerve sheath during this surgery, facilitating the fenestration of the sheath and visualization of the subsequent cerebrospinal fluid egress. Utilizing a medial conjunctival approach, the Farris-Tang retractor allows for easy retraction of the medial orbital tissue and reduces the incidence of orbital fat protrusion through Tenon's capsule. CONCLUSION: The Farris-Tang retractor allows safe, easy, and effective access to the optic nerve with good visualization in optic nerve sheath decompression surgery. This, in turn, allows for greater surgical efficiency and positive patient outcomes.

Changed trends of major causes of visual impairment in Sichuan, China from 1987 to 2006.

AIM: To study the trends of major causes of visual impairment (VI) in adults in Sichuan, China and evaluate the effect of aging on the trends. METHODS: We used data from the National Sample Survey on Disabilities (NSSD) in Sichuan province conducted in 1987 and 2006. The age-adjusted prevalence of major causes of VI and the prevalence stratified by age in each cause were calculated and compared. The association between age and each cause of VI was also analyzed. RESULTS: Retinal disease increased and became the second leading cause of VI in 2006 while blinding trachoma decreased markedly. Cataract and non-trachomatous corneal diseases were among the leading causes of VI in both years. We found associations between age and causes of VI, with age showing the strongest association with cataract and relatively lower associations with other causes. CONCLUSION: In the last two decades, dramatic changes occurred in the major causes of VI with significantly increased retinal disease and decreased blinding trachoma. Aging of the population might be an important factor accounting for the changed trends of VI. Understanding the prevalence of VI, its major causes and trends over time can assist in prioritizing and developing effective interventional strategies and monitoring their impact.

Optic nerve sheath decompression: a surgical technique with minimal operative complications.

BACKGROUND: The purpose of this study was to determine the safety and efficacy of optic nerve sheath decompression (ONSD) with a medial transconjunctival approach for a variety of indications in a larger population of patients than has previously been reported. METHODS: A retrospective chart review was performed on consecutive patients who underwent ONSD between January 1992 and December 2010. Before ONSD, all patients had documented evidence of progressive loss of visual acuity or visual field, or both. Postoperative follow-up visits were scheduled at 1 week, 1 month, and then every 3-6 months. Main outcome measures were visual acuity, visual fields, and surgical complications. RESULTS: Five hundred seventy-eight eyes of 331 patients underwent ONSD for progressive vision loss due to various indications, which included but were not limited to idiopathic intracranial hypertension (IIH), progressive nonarteritic ischemic optic neuropathy, and optic nerve drusen (OND). During a mean follow-up of 18.7 months (range, 1 week to 10 years), postoperative visual acuity remained stable or improved in 536 of 568 eyes (94.4%) and progressively worsened in 32 of 568 eyes (5.6%). Visual fields remained stable or improved in 257 of 268 eyes (95.9%) and progressive visual field loss occurred in 11 of 268 eyes (4.1%). There were no reported intraoperative complications. The most common postoperative complication was diplopia (6.0%). CONCLUSIONS: To our knowledge, this review represents the largest series of patients who have undergone ONSD for any indication. Our data are consistent with current literature supporting ONSD as a safe and effective procedure for IIH. Other indications for ONSD, such as progressive visual field loss associated with OND, warrant further study. Regardless of the indication, complications following ONSD with the technique described in this report are infrequent.

Prevalence of diabetes mellitus in biopsy-positive giant cell arteritis.

BACKGROUND: We tested the hypothesis that patients with diabetes mellitus (DM) develop biopsy-positive giant cell arteritis (GCA) significantly less frequently than nondiabetic patients. METHODS: We compared the prevalence of DM in patients with positive temporal artery biopsy (TAB) with that in patients with negative TAB via a retrospective study of 215 patients who underwent TAB. Patients were classified as having biopsy-positive GCA if microscopic examination disclosed active or healed arteritis. Patients were classified as having DM if they had a diagnosis of diabetes in their medical history or were taking oral hypoglycemic medications and/or insulin at or before the time of biopsy. In addition, we performed a meta-analysis of 8 previously published articles with a total of 1,401 additional biopsy-proven cases of GCA in patients whose status was recorded as diabetic or nondiabetic. RESULTS: Of 44 cases with biopsy-positive GCA in our patient cohort, only 4 (9.1%) were diabetic at or before the time of biopsy. Of 171 patients with negative TAB, 61 (35.7%) had DM (P = 0.0006). The prevalence of DM among recorded cases of biopsy-positive GCA ranged from 0% to 13.8% in the 8 studies included in our meta-analysis, with a combined frequency of 89 diabetic patients in a total of 1,401 cases (6.35%). CONCLUSION: The low frequency of a positive TAB in diabetic GCA suspects should be considered when formulating an index of suspicion in the evaluation of patients with possible GCA. More research is needed to delineate the nature of the interaction between DM and GCA.

Patients' perception of physician-initiated prayer prior to elective ophthalmologic surgery.

BACKGROUND: Prayer is an important part of many patients' and physicians' lives. There is little data in the literature regarding patients' perception of prayer from or with their doctors. OBJECTIVE: To assess in a masked fashion patients' impression of prayer's role in a medical setting, and their perception of being offered and receiving prayer from their physician. DESIGN, SETTING, AND PARTICIPANTS: Confidential survey of 567 consecutive patients who were offered prayer by their physician before elective eye surgery. MAIN OUTCOME MEASURES: Proportion of patients favoring physician-initiated prayer and weighted Likert responses to various positive and negative sentiments regarding their experience. RESULTS: Survey response rate was 53% (300 patients). Ninety-six percent of patients identified themselves as Christian. At least 90% of Christian patients responded favorably toward their prayer experience to each Likert question. Among the non-Christian patients, the proportion of negative impressions to the prayer experience ranged from 0 to 25%. CONCLUSIONS: Physician-initiated Christian-based prayer before surgery is well-received by a strong majority of Christian patients. Although the data are few, only a minority of non-Christians felt negatively regarding this experience.

Progression of visual field defects in leber hereditary optic neuropathy: experience of the LHON treatment trial.

PURPOSE: To describe the visual fields of patients with Leber hereditary optic neuropathy (LHON), a maternally inherited disorder characterized by bilateral, often sequential vision loss, before and during progressive visual deterioration. DESIGN: Prospective longitudinal follow-up of serial visual fields in patients enrolled onto an open-label, nonrandomized pilot study of topical brimonidine purite as prophylactic treatment after first eye involvement in LHON. METHODS: Nine molecularly confirmed primary mutation patients with LHON with monocular vision loss for less than six months and normal visual function in the other eye were followed prospectively for up to two years. Visual fields were performed on automated perimetry at baseline and on many follow-up visits. RESULTS: Despite normal visual acuity at baseline in all patients, seven patients had some minimal changes in the central visual field of the second eye. All patients had subsequent deterioration of visual acuity, mean deviation, and foveal sensitivity in their second eye. The earliest pattern of abnormality was typically a cecocentral defect enlarging to become a central defect, often with a superior or inferior predilection. The visual field defects in the two eyes of any given patient were remarkably similar. CONCLUSIONS: LHON may be a bilateral condition at onset more frequently than appreciated. Automated static perimetry of the "normal" eye may reveal subclinical findings that typically worsen rapidly over weeks to months to similar central scotomatous damage. Quantitative automated static perimetry is helpful in elucidating the natural history of LHON and in understanding the underlying pathology and pathophysiology of this disease.

Functional visual loss in adults and children patient characteristics, management, and outcomes.

OBJECTIVE: To compare the characteristics of functional visual loss (FVL) in adults and children. DESIGN: Retrospective chart review. PARTICIPANTS: One hundred forty patients diagnosed with FVL over a 5-year period. METHODS: Medical records of these patients were reviewed and data analyzed using statistical software. OUTCOME: Demographics, underlying organic and psychiatric disease, concomitant psychosocial events, and resolution rates were studied. RESULTS: Functional visual loss, with or without functional overlay, was initially diagnosed in 140 patients and was, in retrospect, a correct diagnosis in 138. There were 56 (40.6%) children and 82 (59.4%) adults (mean age, 13.4 and 40.0 years). The gender ratio, incidence of concomitant psychosocial events, incidence of functional overlay, prevalence of migraine or facial pain, and proportion referred for counseling were similar in the 2 groups. Concomitant psychosocial events were primarily social in children and related to trauma in adults. Thirty-two (39.0%) adults had a history of psychiatric illness, versus 10 (17.9%) children (P = 0.008). Symptoms were bilateral in 65.0% of cases. Functional visual loss manifested as visual acuity (VA) loss only occurred in 26.1% of patients, FVL manifested as visual field (VF) loss only was present in 28.3% of patients, and FVL with loss of both VA and VF occurred in 45.6% of patients. There was no significant difference in children versus adults in the proportion of VA, VF, or both being affected. Functional visual loss with coexistent organic disease (functional overlay) was present in 16.7% of patients. Follow-up information was available for 26.1% of patients. Normalization of any one parameter occurred in 58.3% of patients and was more likely in children. Three patients (2.2%) originally felt to have solely functional disease were subsequently diagnosed with organic disease. CONCLUSION: Functional visual loss is most common in teenagers, is typically bilateral, and involves both VA and VF. Normal VA was proven half the time at initial consultation. At all ages, patients were predominantly female, and one fifth had migraine, facial pain, or coexistent organic pathology. Concomitant psychosocial events were mainly social in children and related to trauma in adults. Psychiatric disease was twice as likely in adults. Normalization of visual function occurred in a majority of patients. Early-onset macular dystrophies and hereditary optic neuropathies may be misdiagnosed as FVL.

Prophylaxis for second eye involvement in leber hereditary optic neuropathy: an open-labeled, nonrandomized multicenter trial of topical brimonidine purite.

PURPOSE: To test a topical agent with purported antiapoptotic properties as prophylactic treatment after first eye involvement in Leber hereditary optic neuropathy (LHON), a maternally-inherited disorder characterized by bilateral, often sequential, visual loss. DESIGN: Open labeled, nonrandomized prospective pilot study. METHODS: Nine primary mutation molecularly confirmed LHON patients with one eye vision loss for less than 6 months and normal visual function in the fellow eye were treated with brimonidine purite 0.15% (Alphagan P) 4 times daily in the unaffected eye for up to 2 years. Visual acuity was the primary efficacy outcome. Secondary measures included changes on automated perimetry and quantification of the relative afferent pupillary defect. RESULTS: There were 8 men and 1 woman enrolled, aged 13 to 54 years (mean 32 years), eight with the 11778 mitochondrial DNA (mtDNA) mutation, and one with the 3460 mutation. Despite normal visual acuity at baseline in all patients, 7 patients had some minimal changes in the central visual field of the study eye. All patients had deterioration of vision in their second eye. In 1 of the 2 patients who had treatment initiated within 16 days after first eye involvement, good visual acuity was maintained in the study eye at 15 month followup, despite a mildly abnormal study eye baseline visual field. CONCLUSIONS: LHON may be a bilateral condition at onset more frequently than appreciated, with asymmetric severity at presentation. Topical brimonidine purite in this dosage was unsuccessful in preventing second eye involvement in recently monocularly-symptomatic LHON.

Retinopathy in patients with diabetic ophthalmoplegia.

PURPOSE: To review the clinical characteristics, prevalence, and severity of retinopathy in diabetics with cranial nerve (CN) 3, 4, and/or 6 palsies, and to determine the relationship between type and duration of diabetes mellitus (DM), presence of retinopathy, and occurrence of CN palsy. DESIGN: Retrospective, comparative cohort study. PARTICIPANTS: Chart reviews of 2229 patients with CN 3, 4, and/or 6 palsies were performed at the Bascom Palmer Eye Institute (BPEI) from January 1991 through December 1997 and at the Dean A. McGee Eye Institute (DMEI) from January 1994 through July 2001. A total of 306 patients qualified for the study group. The Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) was used as a control. METHODS: Demographic and clinical data were extracted to determine characteristics of patients with diabetic ophthalmoplegia. The subsets of data regarding type of DM and level of diabetic retinopathy in the study population were compared with the WESDR control data for statistical analysis. MAIN OUTCOME MEASURES: The prevalence of diabetic retinopathy in patients with diabetic ophthalmoplegia. RESULTS: Of 2229 patients at both institutions with ocular motor CN palsy, 306 (13.7%) were associated with DM. The frequency of CN involvement was 6 (50.0%), 3 (43.3%), and 4 (6.7%). There was a total of 12 patients (3.9%) with consecutive palsies and 8 patients (2.6%) with simultaneous palsies (5 unilateral and 3 bilateral). At both institutions, the prevalence of retinopathy controlling for duration of DM was lower in both insulin-dependent DM (IDDM) and non-IDDM (NIDDM) type II diabetics as compared with controls (BPEI, P = 0.009 and P = 0.005; DMEI, P = 0.004 and P = 0.29). When data from both locations were combined, the difference was even more significant (IDDM, P = 0.001 and NIDDM, P = 0.006). There were no significant differences between the two institutions in gender, type or duration of DM, age at presentation, or frequency of CN involvement. CONCLUSIONS: Diabetic ophthalmoplegia most commonly involves CN 3 and 6, with relative sparing of CN 4. Multiple cranial nerves are affected simultaneously in 2.6% of cases, and consecutive palsies occurred in 3.9% of cases. Type II diabetics with ocular motor CN palsy have significantly less diabetic retinopathy than do controls. This may imply a different pathophysiologic mechanism for these two microvascular complications of DM.

Surgical management of skew deviation.

There are no published data on the outcomes of realignment surgery for skew deviation. A retrospective chart review disclosed 10 patients who had undergone surgical correction of skew deviation by three surgeons at a single institution between 1991 and 2002. Nine of 10 patients had satisfactory relief of diplopia with an acceptable field of single binocular vision. Vertical rectus recession or resection was the most common procedure. Four patients required more than one procedure. For nonalternating hypertropias, resection of the inferior rectus muscle or recession of the superior rectus muscle of the hypertropic eye was successful. For alternating hypertropia, resection of both inferior rectus muscles was successful. Oblique muscle surgery was not associated with good outcomes.